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76 A964 —SCE ete - 9-71 APP TION FOR P T
HEATING - VENTILATING - Al ONDITIONING
COUNTY OF LOS ANGELES BUUIILEINNG , S
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION LOCALITY
NEAREST
CROSS ST.
FOR APPLICANT TO FILL IN OWNER
(PRINT OR TYPE ONLY)
MAIL
NO. TYPEOFAPPLIANCEOR EQUIPMENT FEE ADDRESS
CITY TEL.. NO.
ABSORPTION UNIT, BTU
CONTRAC R
AIR HANDLING UNIT, CFM
ADDRESS
BOILER, BTU CITY TEL. NO.
COMPRESSOR, BTU (I STATE LIC.
LICENSE NO. CLASS
VENTILATION SYSTEM DISTRICT NO. GROUPje�ONEEaaEo er
EVAPORATIVE COOLER �I p
FURNACE: FAUGRAVITY U
�L004 BTU INSPECTION RL CO RD
m
HEATER: SUSPENDED NIT_ C:)
WALL Lu
w
a.
• z
Plan check fqe 25% of above. See reverse,
PERMIT ISSUING FEE S s Do
TOTAL FEE
PLAN CHECK APPLICANT
NAME
A DDRESS
CITYjUj:pjp i TEL.NO.QJ :261'2
5
I HEREBY 2C KNOW LEDG THAT I HAVE READ THIS APPLICATION
L
STATETHAT THEABOVE Il CORRECT AND AGREE TO COMPLY
ALL ORDINANCES AND LAWS REGULATING HEATING, VENTI- APPROVALS DATE INSP[CTOR'S SIGNATURE
NS, AIR CONDITIONINO.
RO UG H
HER aY CERTIFY THAM I AM MOT ACTING IN VIOLATIOXHAPT fl ON a, E BU XEII NO PROFESSIONAL FINA
OF TH T CALIF A.
NATURE PE IT VALIDATION CK, M.O. CASH
PERMITT
PLAN CHECK V CK M.O. CASH /
LAP_ 4 G✓? 73 DEC 4 1 D
SEI BACK OF APPLICATION FOR COM PL£'rE FEE SCHEDULE
X-OW DPW
hereby -1"I WORKERS
Ihave a o�irtttflo4 a of oo sa t two self Insure, 91� APPLICATION FOR PERMVIIT, �I�E .. �E��
or a "rtMcafe of Workers'Compsniatlon Insurance, or a oertlfledHEATING-VENTILATING-AlR CONDITIONING
copy thereof(86o.3800 Lab. C.)
IPWy f'lo' c—nparry' COUNTY OF LOS ANOFIES DEPT OF PUBLIC WORKS BUILbINQ AND SAFETY DIV.
❑ :Certified copy Is hereby tunitshad.
Certified oopy Is filed with the ooufrty btdkkV tnapection FOR APPLICANT Toil TYPE OO FILL IN AD1��
Sate , Applicant LOCALITY `
NQ. TYPE OF APPL1gNCE OH EOUIPUENT FEE
NEARE
a�:M IcATE OF D0 AF k>N FROM WORt0=Fi8' �
CObI PENSATK>j.W SIJ RANGt7Nff Bl U E CF1068 8T. L— y .
(l-hls section need not be oomplefed tf the wont Invotved b1'the O'Gedlp PARCE1L
pehtift ls'for one hundred"Lan($100)or tees.) AIR HANDUNG LINT CFM
DIeTTrcT ND PFADC20M er
J certify.thpt In the pertormsnce of the.,work for which this permit'
Is Issued, I shalt not employ my person In any'manner sd.ae to BTU
:•become subject to the Workers'Compensation Laws. 0 .
BTU
APPFMALA DATE HWEL s�TuM
Date Atpplicant VENTILATION SYSTEM
NOT[dE--TO APP.1,,ICANT: If, after making this Certificate of ROUGH
6cernpf)on, you should become sub)ect to the Workers'Compensation EVAPORATIVE COOLER
'provislbhs of the Labbr.Cdda, you must forthwith oomptywith such FINAL
0mvlslons or.thle permit shall be deemed revoked. FURNACE: , FAU GRAVITY
LFCENSED CONTRACTbRS DECLARATION FLOOR til ll VALIDATION r:
i.hbreby affirm that I em Ilcetlsed.under provisions of Chapter B TEFL, SUSPENDED U
ANTI
(oommenoing with'8totlon 7000) of Division 3 of the Business and HEAWALL
Prnfesslons Code, and my Iloah"Is In full forc6 and effect-
License Nor Lb.Class-
pay.
Conlreo9or-1�50 _ Dots fL
c.)
❑ I am exempt under Seo. Plan check foe'
B.t,P.C.for this reason_ PERMIT J8SUING FEE i /3
fie: TOTAL FEE dL) W
(L
0%NER-9UILDER DECLARATION PLAN CHECK APPLICANT Z
I hereby aMrm that.I am Q"mpt from the Contractor's License Law N
for the followangxaaaon (8ectlon 7031.6, Businbes and Professions ,.
Code): ADDRESS u
❑. I, as owner of the property, or my,employees W" WQges• ACCT.T
ee their sole comp.ensatlon, wlJl do the,work and the My TEL NO,
structure Is not Intended cr offered for sWe (Section 7044, 3307 23.GO
Business and Professions Cotte). OWNER' I
Ir, as.owner of the property,'•am•exoluslvely oontrscting 1 TS
AIAIt TOTAL LJ
_
with licensed contraotors to oonstruct the projeo4 (§6c- Appy
tion 7044, Bualnees and Professlons 4aode). TtJ �-Y .
. CON8TRLCnON LENDING AGENCY CITY TEL NO. C+E(:Vi ; ,*CO
I hereby affirm that there-Is a construotlon lendingagency for
Ihe'performanoe of the-work for which-this permit Is Issued T ' lrfl-IfiLi ■00
(84dc,3007,-Ctv.C.).
ADDRESS
I,�s Name
C" TEL NO. D�QDQ7-1770 t i. .' 11r<,1 q��1]
Lender's Address BTATE LIC. 71h7+� 1 Lt
I corttfy that I have read this appllcatton and state that the above 1JC13lSE NO. CLA88
InfDanation.W correct- I agree to comply with all County ordlnancee
and State laws relating to bulkgng constn t on,apd hereby puthorize
repreaerttativee of this County to enter upon the above-mentioned
apectio SEE REVERSE FOR EXPLANATORY LANGUAGE